Medical Tourism and Travel: What it Means for Your Hospital

Many hospitals and other players in the healthcare industry have been taking careful note of the increasing talk of "medical tourism" and "medical travel," often with an eye on strategic investments related to what is apparently a fast-growing market. With healthcare organizations under pressure to enhance payor mix, and facing tough competition for patients, it is reasonable to ask, "why not bring in distant patients who are willing to travel to receive care?"

But medical tourism may not be the financial panacea that cash-strapped hospitals envision. Any organization factoring medical tourism into their strategic plans should take a close look at what's actually happening in this nebulous and challenging market. In fact, their best opportunities may lie in helping less-developed nations develop their own healthcare capacity to obviate the need for their citizens to obtain world-class healthcare outside of their borders. This is a classic win-win scenario for both the hospital helping build the medical infrastructure and expertise and the country receiving this assistance.

Outbound medical tourism and travel

The unclear thinking about medical tourism and travel starts with what the terms actually mean. Let's first separate inbound and outbound travel, from a U.S. provider's point of view. Outbound medical tourism or travel typically involves a U.S.-based patient taking a trip overseas to receive a treatment — usually one that's expensive here but may be substantially less so at the destination. Cosmetic surgery, hip replacement, even cardiac surgery are among the procedures that U.S. patients have traveled to receive. The motivation is generally price: Some hospitals in some countries have, in one way or another, gained a reputation for performing quality work at relatively low cost. For patients facing an expensive elective procedure not covered by their insurance plans, traveling to a low-cost provider overseas can indeed provide significant savings.

Since some of these hospitals are in regions that also have tourist appeal to international travelers, patients may actually be tempted to put together a package deal, with the savings on the procedure effectively subsidizing the tourism. The tourism might even be a major motivation for the trip. In such cases, it seems fair to refer the phenomenon as "medical tourism." Those cases for which the medical procedure is more or less the sole motivation for the trip, on the other hand, can more reasonably be lumped under "medical travel." Not everyone makes this sort of differentiation — in fact, the industry is distressingly inconsistent in defining the terms, when it bothers to define them at all — but the different motivations make for a potentially useful distinction.

Medical travel is almost certainly more common than medical tourism, simply because the pleasures of tourism don't jump easily into the minds of most people facing a significant medical procedure and looking to save money on it. For patients in the United States, medical travel is essentially shopping internationally for lower-cost care. An industry has sprung up to facilitate and aggressively promote the medical travel industry — if it can be called an industry — marketing it to potential customers with sophisticated advertising and public relations efforts, and receiving much mass-media attention. And a relatively small number of hospitals and clinics around the world have created strong profit centers by specializing in providing these services to international patients.

Inbound medical travel

The situation with inbound patients is a very different one. For one thing, forget about tourism. Johns Hopkins Medicine receives a fairly steady stream of overseas patients at its Baltimore and other campuses, and rarely do we encounter patients or families whose decision-making wasn't entirely based on medical considerations. (Which is not to say that after the decision is made to come here, there can't be a tourist stay tacked on.)

What's more, that decision is rarely price-driven for inbound patients. Care and treatment in the United States generally costs more than in other countries. As a result, inbound patients are frequently receiving treatment here at considerable expense, versus free or highly subsidized treatment in their home country. These patients come here to seek the services of leading specialists or access to top-notch expertise, equipment, facilities and general levels of care that simply may not be available in their own countries. The needed care in their home countries may require long waits of months or even years. Or they may require especially complex diagnostic services or cutting-edge treatment that is only rarely performed in their country.

How much medical tourism or travel is actually taking place? All kinds of impressive numbers are thrown about, but none of them have been put together as the result of careful studies by government, academic, or other reliable, objective parties. In fact, there is an extreme paucity of trustworthy data on the subject. It would be prudent to be especially skeptical of the enormous, self-reported travel-patient numbers claimed by some overseas hospitals, especially given that these numbers can sometimes exceed the hospitals' maximum capacities. These figures are also likely heavily tainted by the fact that there appears to be no effort to filter out from the data from the sometimes large number of expatriates who live in the country of treatment, and who naturally seek treatment at their local hospital; they ought not to be considered medical tourists or even travelers. Most governments don't issue special visas for medical travelers, omitting what would otherwise be an easier way to track them and don't otherwise make special efforts to count them. The United States is no exception: Medical travelers generally come here on tourist visas. Meanwhile, it probably goes without saying that figures bandied about by medical-travel industry spokespeople should be regarded with some wariness.

What it means for hospital leaders

And that's the first point that U.S. hospitals thinking of investing in programs intended to attract and service inbound medical travelers ought to take into account: The market is probably a lot smaller than they've been led to believe. Another is that most hospitals will find it extremely difficult to influence potential traveling patients to choose their hospital over other U.S. hospitals. These patients tend to rely on the direct referral of their home physicians, family members or close friends and colleagues. To the extent that they "shop around," they look for hospitals with outstanding reputations for leading-edge expertise and quality of care, and typically limit their choices to a handful of the most highly regarded academic medical centers in the United States. That's not to say many other U.S. hospitals, including better-quality community hospitals, couldn't do an excellent job of caring for these patients. It's just that they have no competitive edge with which to pull these generally price-insensitive patients away from the top medical centers. Even terrifically managed hospitals making large investments in care quality and marketing aren't likely to make much of a dent in the market.

And if somehow they did attract overseas patients, they might well be caught off guard by the accommodations these patients often require. They or their families might speak no English, and require interpreters who specialize in particular dialects of particular languages. The cultural mismatches can be significant, too. Many of these patients are highly affluent and expect luxury-hotel-like conditions, high levels of privacy and constant personal attention to myriad wants or needs. They may expect the hospital to take care of all travel arrangements. Some overseas patients regard appointment times as rough, suggested guidelines for when to show up. Some will insist that the physician only address the husband and not the wife, even when the wife is the patient. Some will refuse to see a female physician and some may treat nurses not as respected members of the clinical team but as personal servants. Such patients aren't being rude or stubborn or ignorant; they are simply adhering to the norms of their cultures. Hospitals not fully prepared to accommodate or demonstrate flexibility in dealing with these differences won't have good experiences or garner positive word of mouth. Even payment arrangements can be complex for hospitals that don't have any expertise in dealing with overseas financial systems.

It's possible that the market will grow or shift in some way that could make it more worth pursuing medical-travel patients over time. But, in fact, there's some reason to believe that the market may have already peaked. Many nations with healthcare systems currently considered below U.S. and Western European standards are becoming more concerned about it. In particular, increasing affluence, democratization and information access are leading populations of less-developed countries to feel the health care gap more acutely, and there is a growing push to narrow it. Sending patients off to the United States for treatment, as they often do now, is not a medium- or long-term solution. Rather, these countries recognize that they need to strengthen their own systems to better serve the wide population. Governments and healthcare institutions in these countries are increasingly working to do so.

In fact, many of these institutions are turning to the United States for expertise in building higher-quality, higher-capacity healthcare systems. That's likely the faster-growing business, and it's one that more U.S. hospitals should take a closer look at. With good health care going global, there may well be less and less reason for anyone to be a medical traveler. And that's surely a positive trend: People should be able to get good care locally and to enjoy tourism without the "medical" part.Steven J. Thompson, MBA, has more than 25 years experience in various positions within academic medicine and academic health centers. Mr. Thompson is the founding chief executive officer of Johns Hopkins Medicine International JHI, a position he currently holds. After six years as senior vice president of Johns Hopkins Medicine, he returned to the helm of JHI in 2011. Johns Hopkins Medicine International was established as the arm of Johns Hopkins Medicine that provides a focus for all international activities. It is the mission of this organization to establish international programs and businesses that are consistent with and support the Johns Hopkins Medicine mission of excellence in clinical care, research and teaching. Mr. Thompson has a particular interest in identifying innovative ways for Johns Hopkins to collaborate with a wide range of affiliates to work towards the common objective of improving health and health care delivery around the world.